Nursing diagnosis: Chronic Pain Goal: relief of Pain and discomfort NURSING INTERVENTION 1.

Use pain scale to assess pain and discomfort characteristics: location, quality, frequency, duration, etc. 2. Assure patient that you know that pain is real and will assist him or her in reducing it. 3. Assess other factors contributing to patients pain: fear, fatigue, anger, etc. 4. Administer analgesics to promote optimum pain relief within limits of physicians prescription. 5. Assess patients behavioral responses to pain and pain experience. 6. Collaborate with patient, physician, and other health care team members when changes in pain management are necessary. RATIONALE 1. Provides baseline for assessing changes in pain level and evaluation of interventions. 2. Fear that pain will not be considered real increases anxiety and reduces pain tolerance. 3. Provides data about factors that decreases patients ability to tolerate pain and increase pain level. 4. Analgesics tend to become more effective when administered early in pain cycle. 5. Provides additional information about patients pain. 6. New methods of administering analgesia must be acceptable to the patient, physician and health care team to be effective; patients participation decreases the sense of powerlessness. 7. Encourages success of pain relief strategies accepted by the patient and family. 8. Increases number of options and strategies available to the patient. EXPECTED OUTCOMES Reports decreased level of pain and discomfort on pain scale Reports less disruption from pain and discomfort. Explains how fatigue, fear, anger, etc. contribute to severity of pain and discomfort. Accepts analgesia as prescribed. Exhibits decreased physical and behavioral signs of pain and discomfort in acute pain (no grimacing, crying, moaning; displays interest in surroundins and activities around him). Takes an active role in administration of analgesia. Identifies additional effective pain relief strategies. Uses alternative pain relief strategies appropriately. Reports effective use of new pain relief strategies and decrease in pain intensity. Reports that decreased level of pain permits participation in other activities and events.

7. Encourage strategies of pain relief that patient had used successfully in previous pain experience. 8. Teach patient new strategies to relieve pain and discomfort: distraction, imagery, relaxation, cutaneous stimulation, etc.

Nursing diagnosis: Imbalanced nutrition, less than body requirements, related to nausea and vomiting Goal: Fewer episodes of nausea and vomiting before, during and after chemotherapy. NURSING INTERVENTION 1. Assess the patients previous experiences and expectations of nausea and vomiting, including causes and interventions used. 2. Adjust diet before and after drug administration according to patients preference and tolerance. RATIONALE 1. Identifies patient concerns, misinformation, and potential strategies for intervention. Also gives patient a sense of empowerment and control. 2. Each patient responds differently to food after chemotherapy. A diet containing foods that relieve the patients nausea or vomiting is most helpful. 3. Unpleasant sensations can stimulate the nausea and vomiting center. 4. Decreases anxiety, which can contribute to nausea and vomiting. Psychological conditioning may also be decreased. 5. Administration of antiemetic regimen before onset of nausea and vomiting limits the adverse experience and facilitates control. Combination drug therapy reduces nausea and vomiting through various triggering mechanism. 6. Adequate fluid volume dilutes drug levels, decreasing stimulation of vomiting receptors. 7. Reduces unpleasant taste sensations. 8. Increased comfort increases physical tolerance of symptoms. 9. Multiple factors may cause nausea and vomiting EXPECTED OUTCOMES Identifies previous triggers of nausea and vomiting. Exhibits decreased apprehensions and anxiety. Identifies previously used successful interventions for nausea and vomiting. Reports decrease in nausea. Reports decrease incidence of vomiting. Consumes adequate fluid and food when nausea subsides. Demonstrates use if distraction, relaxation, and imagery when indicated. Exhibits normal skin turgor and moist mucous membrane. Reports no additional weight loss.

3. Prevent unpleasant sights, odors and sounds in the environment. 4. Use distraction, music therapy, biofeedback, self hypnosis, relaxation techniques and guided imagery before, during and after chemotherapy. 5. Administer prescribed antiemetic, sedatives, and corticosteroids before chemotherapy and afterward as needed.

6. Ensure adequate fluid hydration before, during and after drug administration; assess intake and output. 7. Encourage frequent oral hygiene. 8. Provide pain relief measures, if necessary. 9. Assess other causes of nausea and vomiting, such as constipation, gastrointestinal irritation, electrolyte imbalance, radiation therapy, medications, and central nervous system metastasis.

Nursing diagnosis: Imbalanced nutrition, less than body requirements, related to anorexia, cachesia, or malabsorption Goal: relief of Pain and discomfort NURSING INTERVENTION 1. Teach patient to avoid unpleasant sights, odors, sounds in the environment during mealtime. 2. Suggest foods that are preferred and well tolerated by the patient, preferably high calorie and high protein foods. Respect ethnic and cultural food preference. 3. Encourage adequate fluid intake, but limit fluids at mealtime. RATIONALE 1. Anorexia can be stimulated or increased with noxious stimuli. EXPECTED OUTCOMES Exhibits weight loss no greater than 10% of pretreatment weight. Reports decreasing anorexia and increased interest in eating. Demonstrates normal skin turgor. Identifies rationale for dietary modifications. Participates in calorie counts and diet histories. Uses appropriate relaxation and imagery before meals. Exhibits laboratory and clinical findings indicative of adequate nutritional intake: normal serum iron levels, normal hemoglobin, and lymphocyte levels, normal urinary creatinine levels. Consumes diet high in required nutrients. Carries out oral hygiene before meals. Reports that pain does not interfere with meas. Reports decreasing episodes of nausea and vomiting. Participates in increasing levels of activity. States rationale for use of tube feedings or parenteral nutrition. Participates in management of tube

2. Foods preferred, well tolerated and high in calories and protein maintain nutritional status during periods of increased metabolic demand. 3. Fluids are necessary to eliminate wastes and prevent dehydration. Increased fluids with meals can lead to early satiety. 4. Smaller, more frequent meals are better tolerated because early satiety does not occur. 5. A quiet environment promotes relaxation. Social interaction at mealtime increases appetite. 6. Wine often stimulates appetite and adds calories. 7. Cold, high-protein foods are often more tolerable and less odorous than hot foods. 8. Supplements and snacks add protein and calories to meet nutritional requirements. 9. Oral hygiene stimulates appetite and increases saliva production. 10. Pain impairs appetite. 11. Nausea and vomiting increase anorexia. 12. Increased activity promotes appetite. 13. Relief of anxiety may increase appetite.

4. Suggest smaller, more frequent meals. 5. Promote relaxed, quiet environment during mealtime with increased social interaction as desired. 6. If possible, serve wine at meal time with foods. 7. Consider cold foods, if desired.

8. Encourage nutritional supplements and high-protein foods between meals. 9. Encourage frequent oral hygiene. 10. Provide pain relief measures. 11. Provide control of nausea and vomiting. 12. Increase activity level as tolerated. 13. Decrease anxiety by encouraging verbalization of fears, concerns, use of relaxation techniques, and imagery at

mealtime. 14. Position patient properly at mealtime. 15. For collaborative management, provide enteral tube feedings of commercial liquid diets, elemental diets, or blenderized foods as prescribed. 16. Provide parenteral nutrition with lipid supplement as prescribed.

17. Administer appetite stimulants as prescribed by physician.

14. Proper body position and alignment are necessary to aid chewing and swallowing. 15. Tube feedings may be necessary in the severely debilitated patient who has a functioning gastrointestinal system. 16. Parenteral nutrition with supplemental fats supplies needed calories and proteins to meet nutritional demands, especially in the nonfunctional gastrointestinal system. 17. Although the mechanism is unclear, medications such as megestrol acetate (Megace) have been noted to improve appetite in patients with cancer and HIV infection.

feedings or parenteral nutrition if prescribed.